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Sterilization in Norway - a dark chapter?

In 1997, Norway and Sweden received a heavy beating in the media upon the revelation that sterilizations had been routinely performed by the state as an instrument of social policy up until the 70s. Whilst international opinion was quick at hand to condemn the sterilizations and did not shy away from immediate comparisons to "Third Reich" practices, the facts and figures remained murky, unclear or even plain wrong. But how many sterilizations had really taken place, and more importantly, how many had been conducted against patients' wills? Siri Haavie investigates the reasoning behind the sterilizations and asks whether it is time to reassess our sometimes all-to righteous moral outrage on sterilization.

Late in the summer of 1997, when I was a student in a British university, I woke up to the news that tens of thousands of people were victims of sterilization policies that had been pursued in the Scandinavian countries from the 1930s and well into the 1970s. Later in the day, one of my professors came up to me and asked how I could hold my head high when I came from a country with such a dark history.

Newspapers reported that more than 60,000 Swedes and 40,000 Norwegians had been sterilized against their will, and that the sterilizations were motivated both by racist thinking on eugenics and by the economic interests of society. To rid society of “genetic inferiority” – ethnic minorities, the mentally retarded, the insane and other “deviants”, who also taxed the social services budget of the Welfare States, had been the main objective of the policy of enforced sterilization.

The history of sterilization in Scandinavia was put on the agenda through Gunnar Broberg and Mattias Tydén’s book Oönskade i folkhemmet. Rashygien och sterilizering i Sverige (1991) [Unwanted in the Welfare State. Eugenics and sterilization in Sweden] and Eugenics and the Welfare State. sterilization policy in Denmark, Sweden, Norway, and Finland (1996), edited by Gunnar Broberg and Nils Roll-Hansen. It was, however, one man in particular who through his reporting in Sweden’s most influential newspaper, Dagens Nyheter, brought the “exposures” out to the world: the journalist Maciej Zaremba.

Zaremba drew a parallel between the Scandinavian sterilization policy and the policies of the Third Reich, though he drew attention to a basic ideological difference: In Germany it was the Nazis that had shown the most willingness to cleanse themselves of “genetic inferiority”and “socially inferior” types, while in Scandinavia it was the Welfare State that had been the driving force behind the policy of eugenic cleansing: A combination of strong social conformity, racist thinking on eugenics, a concern for the public purse, and a nearly boundless belief in the progressive potential of science and social planning had made sterilization by force an attractive tool of policy. Hence, programmes of sterilization by force were not confined to authoritarian regimes; they had been implemented – and hushed up – even in countries known for their liberal tradition and their policies for helping society’s less fortunate.

Zaremba’s articles received international attention. On 30 August 1997, The Independent in Britain informed its readers “Swedes have been shocked to discover this month that the policy was scrapped only in 1976, 31 years after the Third Reich”.

The comparison with Nazi Germany drew criticism from several quarters, and the alleged scale of the forced sterilizations was soon revised to a far lower level. The understanding remained, however, that large numbers of morally reprehensible sterilization procedures had been carried out, and that there were not only concurrent in time but also ideological affinities between eugenic thinking and the Welfare State policies of the Social Democrat parties.

A need for nuances

In their ardour to expose murky ideological currents, “the champions of ethics”, well-meaning politicians and mud-raking journalists ended up criminalizing an important and largely well functioning practice in Norway’s social and medical history. Not only did the 1990s exposure lead to top stories in international media, it had also entered the prevailing climate of thought that the sterilization policy was a “dark chapter” in our immediate past. In the international professional literature, references to the shocking number of victims of sterilization policies in the Welfare States keep turning up, so does the example of Scandinavia as a bugbear in debates on genetic testing and therapies, and the potential for selection or rejection of individuals or characteristics.

The issue of Scandinavian sterilization policies is, however, too important for biased accounts and misrepresentations of the facts to be allowed to continue to hold sway. Focusing on Norwegian policies and practice, I aim to introduce some nuances into a field that is ripe with frightening tales. I will try to address some issues that I believe to be at the heart of the matter: Are there people in society who ought not to have (more) children and, if so, what solutions are there? My aim is to examine some of the underlying tenets in the debate over sterilization and the use of force or coercion.

Motives and target groups

Sterilization is an efficacious method of contraception; in principle it is an irreversible procedure. The access to sterilization for the purpose of contraception has been governed by Norwegian legislation since 1934 when an act was passed against one vote by the Storting, Norway’s parliament. The act did not cause much professional disagreement or much popular reaction. Sterilization became a theme of public debate only as late as in the 1990s; it was by then assumed by many that sterilization of mentally retarded or insane people is morally reprehensible.

The provisions in the Act relating to access to sterilization etc of 1934 included not only sterilization but also castration. A sterilization procedure aims at inducing infertility by cutting the uterine tubes in women or the vas deferensia in men. Castration, on the other hand, is intended to affect a person’s mood by removal of the testicles or ovaries. A medical indication was introduced for castration, as it was for lobotomy, and the act opened up for castration intended to prevent sexual assaults.

The physician Karl Evang (1902-81), later director-general of the Norwegian board of Health and a towering presence in Norwegian public health policy for several decades, brought criticism to bear on the fact that the act would cover two utterly different types of invasive procedures that involve sexual functioning. He thought it extremely ill advised to lump sterilization and castration together under the generic term of “sexual surgery”:

Castration is an operation that stunts a human being and changes him or her in an extreme way and in an unfortunate direction. It is rightly seen as a mutilation and has during all times been surrounded by an atmosphere of horror, terror and disgust. There is no doubt that this atmosphere has also spread its contagion to the sterilization issue and raised difficulties with a rational use of this operation, which in many cases is beneficial, or even necessary.1

Evang also thought it objectionable that the act covered three completely different target groups for sexual surgery: sexual offenders, carriers of an unfortunate hereditary disposition, and mentally adequate people who wished to avoid having children.

It is exactly this mixture of different motives and target groups that has come to characterize so much of the sterilization debates in the 1990s. The result has been an admixture of sentimentalism and facts – a fertile soil for myth making and sensationalism in the media. I would, therefore, like to point out very clearly that my concern here is with sterilization as a contraceptive method.

Let us start by disposing of some myths: sterilization does not do away with the sex drive or the ability to have intercourse. The large majority of men who have a vasectomy notice no change in the amount or quality of the seminal fluid they produce (the seminal fluid is not secreted by the testicles). Their ejaculation remains the same. Women who have undergone sterilization keep their menstruation. Side effects are very rare.2

A tale of two theses

In his painstaking study of sterilization and castration of vagrants in Norway under the 1934 Act, historian Per Haave also examined the Norwegian sterilization practice generally. His most groundbreaking finding is, however, not that there have not been cases of objectionable practice, but that there is no evidence to the effect that sterilization procedures were carried out in the context of a deliberate public policy directed against certain groups of the population: The vagrants were never targeted,3 and there was never a systematic sterilization programme for mentally retarded people based on political decisions or political/administrative directives. In spite of the forceful rhetoric and repeated requests for simplified access to sterilization of the mentally retarded, not least from their caregivers, Haave assesses the number of sterilizations in this group to be relatively low.

Neither Haave nor historian Mattias Tydén, in his study of the history of sterilization in Sweden, have found any evidence suggesting a definite relationship between sterilization practice in the Scandinavian countries and Social Democrat Welfare State policies, as was asserted by the authors of Eugenics and the Welfare State (1996). Haave did not find any reference to sterilization as a potential social policy initiative in any of the seminal policy documents on the Welfare State developed by the post-war Labour Party in Norway. A study of the party’s journal Det 20de århundre [The 20 century] during the years 1920 to 1940 also shows that no special attention was given to sterilization in the interwar years; it was, in fact, non-existing as a theme of ideological debate in the party.

The sterilization issue was, however, and Haave documents this, integral to Norwegian post-war health policy, a programme that drew heavily on ideas derived from the medical specialty of public health and in which hereditary factors as well as social and economic conditions were seen as causing ill health and distress. This political programme was implemented by strong personalities in the Labour Party, with Karl Evang in the vanguard. There was, however, a virtually complete political consensus on the issue of sterilization and a lack of broad public interest. Indeed, sterilization was never mentioned in an election manifesto in Norway between 1920 and 1977.4 Sterilization was not an issue of party politics; it was hardly a political issue at all.

How many were sterilized?

Between 1934 and 1977, a total of slightly less than 44,000 sterilization procedures were performed in Norway under the 1934 act. It was, however, only from the mid-1960s that the act’s potential for family planning was utilised by more than the few: More than 75 per cent of the procedures were carried out after 1965; well over 40 per cent were in fact carried out during the last four years that the act was in force.5 As much as 95 per cent of the procedures were carried out on mentally adequate persons who had themselves asked for, or consented to, a sterilization procedure. Less than 5 per cent (well above 2,000) were carried out on persons defined as mentally abnormal; of these, less than half were classified as so mentally deficient/incapacitated that they were unable to understand the nature of the procedure. We know, moreover, that a large number of people – for many years the majority – were sterilized on a medical indication (sterilization because a pregnancy might endanger the life or health of the woman). This was an indication that went beyond the scope of the act; a medical reason might be given even though the procedure was in fact chosen for social reasons.6

How many of the sterilizations carried out in Norway should be defined as forced sterilizations? How many people have been manipulated, have felt that they were pressured or coerced, or have been sterilized against their expressed will? The answer depends partly on the definition of concepts, partly on empirical data, partly on normative approaches to the interpretation of historical sources. The Committee on Criminal Law Reform that drafted the bill for the 1934 act, was, however, of the opinion that they had secured a legal basis in which voluntary choice was crucial.

“An act of distinct liberalism”

When the Sterilization Act was passed in Norway, sterilization had already been practised for several years, though it was a criminal offence under the Penal Code unless it was done in a “state of emergency”. The authorities were aware of the fact that the medical indication was being stretched; hence it was considered necessary for the medical profession as well as the patients to have the protection accorded by law.

“The greatest benefit rendered by this act is that it greatly extends the access to sterilization on the basis of the individual’s own wish,” so claimed Karl Evang in an article in the Tidsskrift for seksuell oplysning [Journal of Popular Sexual Information].7 Sterilization could now be carried out in persons above 21 years of age who wanted the procedure, provided that the application included a “legitimate reason”. Which reasons were, in fact, legitimate was not specified; hence, the act provided a great scope for discretionary decisions. Ragnar Vogt (1870-1943), psychiatrist and member of the Committee on Criminal Law Reform, characterised the draft for a new Sterilization Act as “an act of distinct liberalism”. In his view, the “real leitmotiv” of the act was that “persons who cannot or should not assume the obligations of parenthood – or new obligations of parenthood – shall be allowed to be spared thereof, if need be through sterilization.”8

Free will was the guiding principle in the act. Physical coercion was not allowed. The person in question had to apply for or consent to the procedure him or herself – if he or she were able to do so – before the sterilization could be carried out. However, the act did open up for sterilization without consent of the “insane” and of persons of “deficient mental development and/or permanently impaired mental capacity”9 , but in these cases the procedure could not be carried out without the prior written consent of the person’s legal guardian or, if the legal guardian was incompetent, a person appointed to act on his or her behalf.

As it was not expected that legal guardians would always initiate the procedure, the act authorised that chief constables or the heads of certain types of institutions could apply for sterilization. However, when the application was made by another party than the legal guardian, the legal guardian’s written consent was required.

Applications for sterilization were submitted to the Norwegian Board of Health. If the application came from a mentally adequate person above the age of 21, the matter was to be reviewed by a committee; however, the practice came to be that the director-general authorised the procedure acting alone. The rest of the applications were reviewed and decided on by a committee of experts chaired by the director-general and with four other members (at least one woman, two physicians, and one judge) appointed by the King in council.

“The Magna Charta of the mentally deficient”

The application procedures and the required guardianship were designed to protect against arbitrary and objectionable practice. However, one aspect of the wording of the act drew early criticism, namely that it opened up for sterilization of the insane without their consent. Even before the bill was passed, Dr Evang pointed out that any new provision that exacerbated the far less than adequate protection of the insane under the law was a cause for grave concern. It was far from certain that there were hereditary dispositions to insanity; moreover, unlike what was the case with certain forms of mental deficiency, there was not the same absolute certainty that the patient could not recover:

In such a case, a sterilization procedure carried out with only the consent of the legal guardian might give rise to the most serious distress and reveal itself to be an injustice of the grossest kind. The draft is very guardedly worded on this point. Everything will depend on that the act, if enacted the bill is, is also enforced reticently and conscientiously.10

Dr Evang’s objections did not bring about any changes of wording in the act itself, but in two subsequent guidelines to the act (of 1938 and 1950) the requirements for sterilization without personal consent where tightened up. The latter guideline came when the expert committee (chaired by Dr Evang) had dismissed a growing number of applications on the grounds that the committee did not find evidence to the effect that the person in question was unable to give his or her consent or that other legal requirements were not complied with. Only persons with highly deficient mental development and/or permanently impaired mental capacity (defined as persons in whom there is no sense of understanding of what the procedure implies) and certain chronically insane persons could now be sterilized without their consent.

During the German occupation of Norway 1940-45, strong criticism was raised against the restrictive practice of the expert committee, the cumbersome application procedure, and the crucial role of the legal guardian. The act’s basic principle of free will was blamed for the small number of sterilization procedures carried out. The Quisling regime wanted a new and efficient sterilization act with a focus on eugenics. Act aimed at the protection of the Norwegian race, in force from January 1943 and suspended in 1945, permitted the use of physical coercion. Only sterilization based on a hereditary indication was allowed.11 Dr Evang later pointed out that “[w]hile under the 1934 act the major concern was the situation of the individual, the public interest was now the main concern – and the starting point.”12

It was not, however, only the Nazis who thought the requirements for sterilization were too stringent. The requirements for sterilization without consent had been criticised even before the war; after the war, too, there were those who thought them too strict. Caregivers spoke up for fewer restrictions on sterilization of the mentally retarded. It was claimed that many of them were not deficient enough for the “enforcement provision” to be used although in fact they were unable to arrive at well-informed decisions, and that their required consent to the procedure caused problems. However, central authorities did not give in to this view. An important concern informing the act had been the protection of the individual under the law. Even though people with a minor mental deficiency in point of practice could be coerced, this was contrary to the provisions of the act.

sterilization of people incompetent to give their consent was generally often understood as an enforced procedure as there was no application or consent from the person in question, but this use of force was not illegal. Early on, Ragnar Vogt was concerned that procedures of this kind should not be considered enforced:

Comparing the action of a legal guardian on behalf of such a helpless person with the use of force against a person of full capacity is a confusion of terms. In fact, the draft from the Committee on Criminal Law Reform precludes the use of an “enforced invasive procedure”, and this is essential to the draft’s whole structure.13

Vogt’s point of view touches on one of the core questions in the sterilization issue. For those who wish to study the magnitude of the use of force under the act of 1934, it might be useful to take a closer look at contemporary practice in this area. The issue of coercion is complex and includes some interesting paradoxes.

New acts, new rights?

Scandinavian sterilization policy is usually referred to as a closed chapter. However, all the countries passed new sterilization acts in the 1970s, which by and large carried on the legislative tradition. There was, however, a material change in the direction of liberalisation: Mentally adequate people over a certain age (in Norway, 25) no longer had to apply for the procedure. The acceptance of sterilization as a contraceptive method had been gaining ground in Norway for several years before a new act came into force in 1978. In this area the act was merely a formalisation of established practice.

The Norwegian as well as the Danish act carried on the old provision that opened up for sterilization without consent of people with such severe mental disease, impaired mental development or mental impairment that they cannot themselves have an opinion on the procedure, and in whom recovery or considerable improvement cannot be counted on. In the Swedish act, on the other hand, the principle of free will is so rigorously established that sterilization of the “legally incapable” is no longer allowed.

Sweden 1987: A mentally retarded girl is denied sterilization on the grounds that she cannot possibly understand what the procedure implies. During question time in Riksdagen, the Swedish parliament, Marianne Karlsson MP advocates an amendment to the Sterilization Act and cites a case in her argument:

I would like to start out by saying that my question has in fact nothing to do with enforced sterilization. My question pertains to the singular cases when a sterilization procedure ought to be carried out, but the person who needs it is not aware of what the procedure implies, or why it is carried out. Still we ought to use common sense – we are always well advised to do so, and particularly in a case like this. […] The mother of a severely mentally handicapped girl in Östergötland do not want her daughter on oral contraception as she is taking potent medication for epilepsy and other conditions. In the home where this 20-year-old girl lives, there are boys who lack all inhibitions whatsoever. The staff is concerned that the girl will get pregnant. […] The wish for a sterilization procedure came up in order to protect the girl. If we are to place human dignity first, we should amend this act. We cannot be oblivious to the fact that the act should have a provision for exceptions in certain cases.”14

Norway 2001: The mother of a mentally handicapped daughter tells Aftenposten, the leading Norwegian broadsheet, that she coerced her daughter into undergoing sterilization: “It is fairly correct to use the word coerce; maybe I even tricked her into signing the application. Still there is no doubt in my mind today that the decision was right.”15

This mother also tells the reporter that she was afraid of being rebuked for also taking her own interests into account. She has had sole custody of her daughter since she was a little girl and could not cope with taking on the responsibility for a young child again. “The words enforced sterilization haunted her mind. The injustice that society had wrought on the less fortunate was a hot topic. Would she herself be met with rebuke from the people around her?”16

Sterilization and human dignity

What do these vignettes tell us about contemporary views on reproductive rights and coercion? The Norwegian vignette suggests that the risk of child neglect was a crucial reason for the sterilization procedure. The girl’s mother also took her own needs into account and assessed the consequences of a pregnancy to be so severe – for her daughter, herself and, if the daughter conceived, for a child – that she believed that coercion and trickery were legitimate options. She fears rebuke from the people around her, but says that she is in no doubt that it was a correct decision.

The county sterilization board, which under the new act (of 3 June 1977 no. 57, as amended) is tasked with reviewing the application, assessed the situation on its merits. The board also knew that there is a strong probability that a child born to mentally handicapped parents will have a difficult childhood, and that genetic as well as environmental factors play their part. Each year approximately 25 children are born of mentally retarded parents in Norway; several of them are adopted at birth, though in some cases the children are taken into care only after some years when a series of intervention have been tried with the parents.17

The risk of neglect was indeed the background when it was proposed in the Norwegian green paper, NOU 1991:20 Protection of the law for mentally retarded people, that “no-one has a right to become a parent” and that “considerations for the child’s welfare are as important, in several cases indeed more important than for the parents’ welfare.”18 But as professor of public law Aslak Syse maintains, there is very limited scope for intervention in relation to a woman in order to prevent her from conceiving or to make her have an induced abortion. If the woman in question understands her situation and the impact of what is suggested to her, no intervention can be made against her express will. If, on the other hand, there is every reason to doubt her ability as a caregiver, attempts at coercion will be seen as a legitimate approach. Under Norwegian law, considerations for the child that might be born take precedence over a person’s wish to have a child.

In the Swedish vignette, the wish to protect the woman is the main motive for sterilization. This young woman cannot use oral contraceptives, and there is a concern that she might get pregnant. Sterilization is seen as the best solution; it is, however, prohibited under contemporary Swedish legislation.

Norwegian legislation, on the other hand, continues to open up for sterilization without consent if the person in question is so severely mentally retarded that he or she cannot make a decision on the procedure. If the mental handicap is so pervasive that it precludes understanding of what the sterilization procedure implies, he or she is considered unfit to assume responsibility for a child. As long as a person cannot assess different alternatives against each other, and a legal guardian is appointed to safeguard his or her interest, the sterilization procedure will not be defined as enforced. Vogt’s mode of argumentation in the 1930s is, in other words, still the guiding legislative principle.

According to Marianne Karlsson, the contemporary Swedish legislation is at crossroads with common sense as well as respect for human dignity, as there are situations in which sterilization “ought to be carried out”. The fear of violating rights has produced a legislation that makes it probable that this young woman will conceive, followed by induced abortion or childbirth and transfer of care and the concomitant suffering for all parties concerned.

It would seem that the reproductive rights of the individual are held in high esteem in Sweden, though a closer look at the practice will show that it is not necessarily so. The 20-year-old woman might have been put on the pill throughout her life without any intervention from the authorities, but she is deprived of her right to sterilization as a method of contraception.

Motives for sterilizing “deviants”

The vignettes above elucidate how the wish to reduce human suffering has been a crucial motive for sterilization. They also show how social and genetic considerations often go hand in hand (for example, because mental retardation makes people unfit for parenthood), and how complex the issue of coercion and enforced procedures may be. Have we adopted different modes of approaching and thinking about these issues compared to those we used to have?

Human genetics is knowledge about the genetic endowment of man; eugenics is genetics applied to improvement of that endowment. In recent years, the sterilization acts of the Scandinavian countries and the way they have been practised have almost exclusively been interpreted as an expression of a breakthrough for eugenic theories and a desire to improve the quality of the population in terms of a narrowly delineated vision of normality. A great deal of research has gone into elucidating which directions within eugenics that came to be decisive for the legislation and the practice in this area and the extent to which mainline science was involved in developing the eugenic efforts.

When the bill for a new Sterilization Act was being heard in the Storting in 1934, the spokesman for the Standing Committee who had prepared the recommendation of the bill, Erling Bjørnson (1868-1959) of the Agrarian Party, started by pointing out to the Storting that the Sterilization Act was an important tool of eugenics inspired by a concern for improving the race:

It is only natural that a farmer was elected as the spokesman for this bill. No-one else has the daily opportunity that a farmer has of noticing the immense advantage that consistent use of eugenics conveys on a farm and, in consequence, on our country. This goes not only for the livestock, but also for all the crops that farming depends on. On the one hand we strive to safeguard the productiveness and vitality of our stocks and crops, on the other hand to rid them of parasites and weeds. Weeds alone in fact drain the farming business of many million a year.19

Bjørnson, later an active member of the Norwegian National Socialist Party (“The National Union”), pointed out that Germany had introduced “enforced sterilization in order to liberate the generations to come from the burden imposed by degenerates”.20 As his speech drew to a close, he extended his gratitude to the eugenicist Jon Alfred Mjøen (1860-1939) for his contributions to the cause.

Racist thinking on eugenics was widely embraced in Europe and North America in the early years of the 20 century and up to the Second World War. There was widespread fear that the European races were degenerating: a necessary social and biological balance was on the brink of being upset. In order to counteract the consequences of “natural selection” having been displaced, the eugenics movement advocated the weeding out of “genetic inferiority” and the protection of the good genetic material in the population.

Extreme eugenic views found expression in the Norwegian debate, in which a turn to biologisation took place. Mr Bjørnson was far from alone in availing himself of metaphors from breeding and from the animal and plant kingdoms. However, Nils Roll-Hansen’s analysis of the Norwegian eugenics debate shows that as early as around 1915 a growing scepticism and critique was noticeable among experts within biology and medicine, who were staunchly critical of the naïve and facile use of genetics in human affairs. Throughout the interwar years, Norwegian geneticists came to close ranks against the popular eugenics movement. Genetic research, they maintained, could prove neither an extensive degeneration of the genetic material in the population nor that the proposed social policies would have the desired effects. sterilization of individuals with inherited diseases would not necessarily obliterate these diseases, notably because several diseases were inherited recessively. Jon Alfred Mjøen, initiator and a leader of the Norwegian eugenics movement, was castigated as a scientific dilettante and ostracized by Norwegian genetic scientists, and his movement never came to have more than marginal influence on Norwegian social policy.21

Poverty, degradation and social distress

Mr Bjørnson and Mr Mjøen’s views were extreme in the public debate over sterilization; in no way did they represent the prevailing view. The broad acceptance of the Sterilization Act should rather be seen in the light of a general preoccupation among the political parties with reducing poverty, degradation and social distress. Per Haave points out that rising unemployment from the mid-1920s brought the public-sector finances under increasing pressure: The number of breadwinners on the dole rose from 85,259 in 1925 to 158,209 in 1935 – i.e. every fifth household in the country. Sterilization was seen as “a means to alleviating social distress as well as to reduce expenditure in a society in crises”.22

A moderate, non-racist form of eugenics was, however, widely accepted by the scientific establishment. It was widespread agreement that knowledge derived from human genetics could be of importance to social policy. In order to uphold scientific standards in research and to keep out dilettantes like Mr Mjøen, a Norwegian Institute of Genetic Research was established in the University of Oslo in 1916.

The Sterilization Act of 1934 opened up for sterilization of the insane and the mentally deficient without their consent. Social as well as eugenic reasons for the procedure were cited – that there was reason to believe that the person in question was not able “to provide for themselves and their offspring through their own labour,” or that “a morbid mental state or a considerable somatic deficiency would be transmitted to the offspring”.23

The leading Norwegian geneticist Otto Lous Mohr (1886-1967) warned against “too great expectations in relation to the noticeable effect of a sterilization act as far as the genetic improvement of the population is concerned”.24 He was, however, in favour of the act opening up for sterilization of the insane and the mentally deficient without their consent, as this “will indeed cover the not particularly numerous cases in which a procedure of this kind is legitimate and justifiable, also from the point of view of genetics”.25 However, Mohr emphasised the social reasons for sterilization:

Many mentally ill individuals (the insane, the mentally deficient etc.) are thoroughly unsuited to be parents and to bring up children, even though we cannot assert in advance that the disease will be transmitted to their offspring. A surgical procedure that causes infertility will in several cases be appropriate.26

In Sweden, too, the social reasons for sterilization were emphasised. Mattias Tydén shows that the view that “those with lesser mental gifts” are unfit to be parents was one of the most prevalent arguments in favour of the Swedish Sterilization Act.

Interpretation of practice

The intention behind an act is one thing, the practice that it brings about quite another. To what extent were the sterilization procedures that were carried out based on social and eugenic indications?

Per Haave shows that social considerations were at the heart of Norwegian sterilization practice, and that applications for sterilization pursuant to the “enforcement provision” seldom gave occasion for doubt among the members of the Sterilization Committee. He quotes Nic Waal (1905-1960), a psychiatrist and member of the Sterilization Committee for many years, who in a speech to the Norwegian Medical Society in 1955 said that “[t]he grounds for sterilization will in these cases always be protective in view of the fate of a child – quite irrespective of eugenic or other indications”.27 According to Haave, Dr Waal pointed to “[what] must be characterised as the governing principle in the expert committee’s review” of this type of cases: “Whether or not the condition was congenital seem to have been of secondary importance; the decisive point was whether the person in question could not be presumed to be able to care for children.”28 Also in relation to sterilization of the mildly retarded, Haave is of the opinion that preventive considerations were given the greater emphasis. “In other words it was primarily the parenting skills of the person in question that came to be particularly decisive in the committee’s deliberations”.29.

In her study of the Danish sterilization practice over the period 1920 to 1967, Lene Koch chose to classify applications for sterilization by whether they were based on purely eugenic indications, purely social, or eugenic and social indications. Koch here applied a very wide concept of eugenics and equated any reference to inheritable conditions with a eugenic reason. Applications based on purely eugenic grounds/considerations turned out to be only a small fraction of the total number of sterilization procedures, while applications with purely social indications approached 50 per cent of the total. Koch concluded that eugenic considerations had played a highly significant role; she thought that the reason why eugenic indications were not mentioned even more often “[must not be] interpreted in the sense that it [eugenics] had a subservient role; on the contrary, it must be understood to the effect that its role was so pervasive and appeared to be so evident to those involved that mentioning it was not always required”.30

“Could it rather be this way, that eugenic indications were not mentioned because they were controversial?” So asked Nils Roll-Hansen as opponent at Lene Koch’s public defence of her doctoral dissertation in September 2000. “[…] Even in those cases where an indication based on biological inheritance was considered relevant, it usually had to be backed by social indications if sterilization was to be broadly accepted”.31 Mattias Tydén is also sceptical of the stated motives. In his public defence of his doctoral dissertation on the Swedish Sterilization Act in April 2002, he pointed out how difficult it was to assess the real motive behind a sterilization procedure. Tydén was of the opinion that the emphasis attached to the conditions under which a child would have to grow up could only be a vicarious motive employed to add legitimacy to the eugenic motives. That the professionals he interviewed in the course of his research accentuated concern for a child’s welfare and individual fate could, according to Tydén, just as well be a reflection in hindsight.32 An alternative interpretation could of course be that the social indication is a real motive that deserves to be taken seriously and not to be treated as a pseudo-argument used instead of giving a controversial eugenic indication.

A neglected dilemma

Does everyone have an inalienable right to have children? The question was raised by Kari Melby, professor of history in the Norwegian University of Science and Technology and an opponent at Tydén’s public defence of his doctoral dissertation. Tydén replied that he could not see that as a researcher he was obliged to address that issue.

When I ask people in the research community about contemporary practice in this field, no replies are forthcoming. How do we today relate to the reproductive issues facing the mentally retarded or severely insane? This has not been seen as a relevant question in the Scandinavian debate over sterilization. Contemporary practice is, according to Lene Koch, “a big issue that has received very little attention”. But she has her misgivings: “At this point one may harbour a well-founded suspicion that the classic welfare-state modes of coercion are now and then in play.”33

Tydén, too, mentions with a few words that there is a continuity in the sterilization issue up to our own time; it is, however, a continuity that he finds deeply problematic: “Although one in this day and age seldom – and in Sweden probably not at all – goes to such a drastic measure as sterilization, there are other methods and techniques, the voluntary use of which we in fact know very little about: oral contraceptives, intrauterine devices, taking a child into care”.34 Not only does Tydén see sterilization as a “drastic measure”, he is also of the opinion that stating that someone is not fit to have children (or terminating a pregnancy for genetic reasons) is tantamount to thinking of that person as inferior as a human being: “In both cases the fundamental tenet is that life can be graded according to what is valuable and what is not”.35

The long and short of it is that the debate over the sterilization issue is characterised by a lack of ability – or will – to conceptualise the fundamental tenets: It is taken for granted that eugenic indications are problematic, that sterilization of the mentally retarded is morally reprehensible, that third party intervention equals objectionable coercion. A small research community, characterised by a high degree of consensus in its approach to the issues, has narrowed down the analysis and defined a number of questions out of the debate.

The objective has been to expose murky eugenic thinking – and rightly so, it is a necessary thing to do. But eugenics is an ambiguous concept: It has changed over time and has been used in several different ways in the literature on sterilization, with resultant ambiguities and misunderstandings. The concept has included racist thinking on eugenics as well as more neutral public health approaches; though it was originally used on the level of populations (safeguarding their quality), it has also been used for genetic indications on the level of individuals.

The search for objectionable eugenic motives has left its imprint on the analysis and the interpretation of data. Another consequence has been a refusal to come to grips with – or a denial of – the existence of a fundamental dilemma: How to act on the fact that there are some people who evidently cannot have care of children? What is curiously missing is wonder about how we come to terms with this dilemma in our own time. One cannot help thinking that this probably reflects a lack of grasp on the problems facing those involved. A basic tenet is that a sterilization procedure is an unwanted and objectionable solution – not a feasible or, under certain conditions, necessary contribution to better quality of life for the individual: A solution that opens up for having a sex life without fear of a pregnancy or supervision by caregivers. A chance of not having children for whom one cannot care. A chance of not being forced into situations that one cannot cope with.

The motives underlying previous legislation should be seen in the light of the actual problems and dilemmas at the time, what solutions were available, and the state of the art of knowledge about the interplay of nature and nurture. Not only have social services been greatly improved since Norway’s first Sterilization Act came into force – the whole life sphere of reproduction and fertility has changed beyond all recognition.

Today, contraceptives are readily available off the shelves in shopping malls and pharmacist dispensaries. In the debate over the earlier practice of sterilization one often searches in vain for an understanding of what methods of contraception were available before the mid-1960s and who were in a position to use them. The impact of the methods of contraception available on sterilization practice in Norway is also overlooked or at the very least superficially treated in the literature in the field.

Between 15 and 20 persons with mental retardation are now undergoing sterilization in Norway per year.36 In addition, an unknown number of people use contraceptive methods that were not accepted, were not as efficient, or simply did not exist at the time when the Sterilization Act of 1934 was in force. When it comes to the choice of using contraceptives, there is, however, a cost involved in giving weight to the choice of the individual and having a high threshold before an intervention is made. In a book by Willy-Tore Mørch et al. on sexuality and mental retardation it is noted that:

One might wish that health personnel that work with potential parents tried determinedly to prevent pregnancies when there is reason to be concerned about the ability of the persons involved to care for children. Usually, concern arises when the pregnancy is under way. Sometimes a child has to be born before caregivers react. The high threshold before an intervention takes place is an impediment to important education and counselling or the prevention of unwanted pregnancies, and it increases the number of painful child care cases.37

Women as victims

We find the tendency to victimisation also in the interpretation of the large number of sterilization procedures on mentally adequate people under the act. On the basis of the available data on procedures carried out it is difficult to assess the number of involuntary procedures, though Per Haave suggests a relatively extensive use of indirect enforcement. When the act was passed, the extension of access to sterilization based on one’s own wish was seen as an important step forward, though Haave calls into question how voluntary these procedures really were. He thinks that this question is of particular relevance in the assessment of practice in the area up until the latter half of the 1960s, “as sterilization was often recommended to women in socially and financially unprivileged families, without these women being informed about other methods of preventing a pregnancy.”38 He goes on to note that sterilization in many cases seems to have been a quid pro quo for being allowed an induced abortion. Furthermore he suggests that the circumstances in which many women lived – what he terms “the force of circumstances” – should be taken into account in an assessment of the history of sterilization in Norway. In all these areas Haave sees traces of indict coercion as a consequence of “the Welfare State failing to do justice to women who for various reasons were in need of temporary infertility, though not necessarily permanent sterility.”39

Neither before nor with the Abortion Act of 1960 was there any authority in law to make sterilization a condition for induced abortion. Research in the field does, however, show that this was done in a number of cases, particularly with women who had had one or more previous abortions. This does not imply that these women were sterilized against their will – they may have thought that the procedure was sensible – but that not infrequently they were coerced into relating to the issue of sterilization at the time of their application for an abortion. This may be seen as an ethically unacceptable aspect of earlier practice. Generally the women were very satisfied with their decision to undergo a sterilization procedure, but in the group that had the procedure at the time of induced abortion there was a considerable proportion that several years later regretted it.40

Quite apart from this, there is no doubt that several doctors had a restrictive attitude to contraception on moral grounds, and some have had little knowledge about contraception in general. Before the pill was registered as a contraceptive method in Norway in 1967 (and the IUD at about the same time) there were, however, not many good alternatives available. The choice was largely between sexual abstinence, sterilization, condoms or the use of a diaphragm. The gynaecologist Per Børdahl at Rikshospitalet University Clinic describes the diaphragm as “a method for grade-school teachers”: it required knowledge and accuracy and one had to have one’s life in good order. The male partner’s cooperativeness was also important in the choice of contraceptive method. An example taken from Elise Ottesen-Jensen (1886-1973), a Swedish-Norwegian pioneer in the field of sexual education, will serve to illustrate the issues involved: A teacher has been in touch with Elise, asking her how she can provide a poor mother of nine children, 35-40 years old, with contraception:

Unfortunately I could not help her with a diaphragm. Childbirths had been so tough on her body that my attempts at fitting a diaphragm were completely futile. What was I to do? Oh yes, Professor Forssner! In this case we should be able to get a sterilization procedure. Getting her husband to understand and to using a condom seemed to me out of the question. […] Professor Forssner had helped me with sterilization procedures in a number of special cases. He did so this time, too. I am not sure who was the happier person around, “the old girl”, the teacher or myself, when the knot was unwound. Page upon page could be written about all the details. But science won at the end of the day and was put to use where it was most needed.41

It was, in other words, not to be taken for granted that all women were able to use a diaphragm or their husbands condoms; for a good many, sterilization was the best or indeed the only course. If it was evident that other contraceptive methods would fail, it was not so strange that doctors refrained from recommending alternative methods. Haave points to the fact that contraceptive counselling was not often mentioned in the case notes that have been studied; he sees this as an indication to the effect that many procedures were carried out without the woman being informed about alternative methods. But the mode of contraception that according to Haave would have been an “adequate solution” was not necessarily available, a real alternative given the circumstances, or wanted by the woman herself.

Norwegian as well as Swedish sources show that the women who applied for sterilization had more children than average; often they expressed the feeling that they had “done their turn” and “could not cope with more”. Why go to all the trouble with using a diaphragm if they had already had all the children they wanted? Haave is, however, concerned about “the force of circumstances” – that a difficult situation, financially and socially, may have forced women to have a sterilization procedure. Here he highlights the changes that have taken place in terms of the social background of those undergoing sterilization. Women from working-class families in difficult financial circumstances were the big user group up to the mid-1960s; in the ensuing years more and more men and middle-class women also opted for sterilization: “This shift is also an expression of a change in the purpose of the procedure: Increasingly, sterilization was used as a family planning method; earlier on it was essentially a solution to difficult social and financial circumstances.” (My italics.)42

As might be expected, we find most working-class women in difficult circumstances among those who underwent sterilization because of a “legitimate reason” up to the mid-1960s. In this group the number of children and the social problems were largest, and more women found themselves in a situation in which applying for or accepting an offer of sterilization was an option. As the middle class expanded and sterilization as a method of contraception became more accepted, then naturally the proportion of women with middle-class background increased. Documenting a shift in class distribution is one thing; it is far more difficult to find evidence to the effect that a shift of this kind is also an expression of a change in the very purposeof sterilization, and that the choice for many working-class women was subject to the force of circumstances. Who, then, defines what constitutes a forced decision?

Is it correct to describe as under the force of circumstances a worn-out mother of four in a flat without a separate bedroom who has a constant horror of getting pregnant yet again? How can we know that this woman did not experience the sterilization procedure as sensible, regardless of her difficult circumstances? Is it not possible that a decision to undergo sterilization is experienced as exercising freedom over one’s own body?

Sterilization of working-class women could be seen as an unwanted solution in a difficult situation; it could also be interpreted as a fairly well functioning help for women, regardless of their circumstances.

There is no doubt that there have been women who wanted more children and chose sterilization as a last resort with a heavy heart, though insinuating, as Haave does, that this was the normal situation for women in difficult circumstances leads to an oversimplification of the debate, the use of coercion is exaggerated, and working-class women defined as victims.

Unanswered questions

No one will deny that reprehensible ideas have been expressed in the Norwegian debate over sterilization, or that objectionable sterilization procedures have taken place. The questions are, however, the extent of objectionable practice, and in what framework of interpretation the sterilization issue in its entirety should be analysed.

The debate over sterilization, as carried on in the mass media in the 1990s, has left an impression of politicians and professionals as stupid as well as evil. Moreover, we cannot disregard the possibility that the debate has contributed to stigmatising sterilization as a method of contraception, with unfortunate effects in contemporary society.

If we consider the group of people for whom sterilization requires an application and the consent of a legal guardian, we may ask: “Are too many or too few now undergoing sterilization?” No one knows. We know little about the need of various groups of people. There has been deficient monitoring of how the Sterilization Act of 1977 has been practised. We do not know how contemporary practitioners, caregivers and close relatives view the desirability of mentally retarded, mentally reduced or severely insane people having children, whether or not they see a sterilization procedure as problematic, and how they assess sterilization in relation to other methods of contraception.

Recently a foreign researcher got in touch with me, wanting to know “the exact number of those who really had undergone enforced sterilization in Norway.” What was I to answer?

109 vagrants underwent sterilization procedures under the 1934 act. Approximately half of them were defined as mentally adequate and signed the application papers themselves; among these, one fourth had between six and eleven children. Several among those who applied for sterilization themselves cited a difficult situation in the home as the reason why they applied for the procedure. According to Haave (2000), women that the Norwegian Mission Among the Homeless and the public authorities considered "vagrants" were more often subjected to enforced sterilization than other women. The figures are, however, so small and the concept of force or coercion so problematic that it can only be said with certainty that the media stories of extensive enforced sterilization of vagrants have been out of all proportion to the facts.

Source: Norwegian Social Science Data Services (NSD)

Haave 2000

According to Haave (2000) there is much to suggest that this "loophole" was primarily a solution for women in difficult circumstances who had an eminently legitimate reason. It saved time as well as expenses (rehospitalization) if the application procedure to central authorities could be dispensed with, and it was usually the doctors who suggested this solution.

Source: Norwegian Board of Health. Because of weaknesses in the contemporary statistical procedures there are no reliable data on the number of sterilization procedures carried out that require a legal guardian's consent.